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6 - Why Failures Occur in the Safe Management of Medications

Published online by Cambridge University Press:  09 April 2021

Alan Merry  and
Joyce Wahr
Alan Merry
Affiliation:
University of Auckland
Joyce Wahr
Affiliation:
University of Minnesota
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Summary

The process of medication management in anesthesia is both complicated (numerous steps) and complex, in that it requires continual adaptation to a continually changing environment. In addition, medication safety depends on systemic factors, some of which involve processes far from the clinical interface. The system in which medications are managed is complex, if only because humans are a key part of this system. The processes of human cognition are particularly complex, and include knowledge, evidence, information, wisdom and expertise. These processes are explored in some detail, including a discussion of short term and long-term memory. Each practitioner responds to an internally developed mental model of the current situation, which may differ considerable from that of other team members. An understanding of complexity and human cognition may often provide an explanation for failure in healthcare: such an understanding provides a foundation for our overall pursuit of medication safety.

Keywords

Medication managementcomplexitysystem errorsnormal accidentsprescription erroradministration errordispensing erroraffordanceshard engineeringsoft engineering
Type
Chapter
Information
Medication Safety during Anesthesia and the Perioperative Period , pp. 87 - 105
Publisher: Cambridge University Press
Print publication year: 2021

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